Surrender Application If you are unable to fill out on-line, Download Print version. Date Dog’s Current Owner Street City State Zip Phone Email I prefer to be contacted by phone email either Dog’s Name Breed Purebred? yes no If Mixed, what breed is it thought to be mixed with? Color/Distinguishing Markings Sex male female Neutered/Spayed: yes no Age How long have you had this dog? Where did the dog come from? How did you obtain this dog? Are you the original owner? yes no Have you contacted who you got the dog from to notify you can no longer keep the dog? yes no If yes, what was the outcome? If not, please contact them before attempting to surrender the dog to IGPR. Do you have an adoption agreement that requires you to return the dog to where you got it from? yes no Why do you want to rehome your dog? If behavioral, have you consulted a behaviorist to attempt to resolve the problem? yes no If yes, what was the outcome? If no, and the problem is behavioral, we suggest you contact your veterinarian for the name of a qualified specialist to help you and the dog. IS THE DOG: Housebroken? yes no Does the dog have accidents? yes no If yes, under what circumstances? Good With: Children? yes no Cats? yes no Dogs? yes no Men? yes no Women? yes no Does the pet chew furniture, wood, get into garbage or otherwise destroy things? yes no If so, when does this occur? Can the pet be left alone (without incident)? yes no For how long? Is the pet crate trained? yes no If yes, will you be providing the dog’s crate with them too? yes no Where is the pet used to sleeping? Does the pet ride well in a car? yes no Jump fences? yes no If yes, how tall? Is the pet afraid of anything in particular? yes no If yes, what? Has the pet ever bitten anyone? yes no If so, who and what were the circumstances: Does the dog bark when someone comes to the door? yes no Bark Excessively? yes no If yes, under what circumstances? Has the pet had any obedience training? yes no If so, what commands does he/she know? Does the pet know any tricks? yes no If so, what are they? When was the last time the pet went to a veterinarian? Veterinarian name Address Phone Is the pet up to date on vaccinations? yes no Enter the date of most recent vaccination: Dhlpp+C: Heartworm Test: Heartworm Meds: Brand of HW used: Rabies Rabies Tag Number RABIES SHOT GIVEN BY: Does the pet have any known health problems? yes no If so, what are they? Is the pet currently taking any medications? yes no If so, what are they? Is the pet friendly with strangers? yes no If not, explain how your dog behaves when meeting strangers: What type/brand of food has the pet been eating? How much per meal? How many meals per day? Is the pet used to having his/her nails trimmed or being bathed? yes no Is the pet protective of his/her food, toys or people? yes no If yes, please explain: Are you able to keep this dog until a suitable home can be found? yes no If not, how long can you keep the dog? Many dogs are euthanized if taken to a shelter as an owner surrender. If no foster homes are available, and the dog must leave your home immediately, are you willing to pay $10 per day for the dog to be boarded for a maximum of two weeks if you cannot keep the dog in your home? yes no If not, why not? Please provide any addition information about your dog’s personality and behavior that will be helpful in finding them a forever home: I understand if my animal is not up to date on vaccines, current on heartworm preventative, or neutered or spayed, there is a $100 owner surrender fee payable to Indy Great Pyrenees Rescue Inc. to help offset the expense of getting the animal treated by a licensed veterinarian. I agree to pay the owner surrender fee because my dog is not up to date on vaccines, and/or on heartworm preventative and/or neutered or spayed. I do not need to pay the owner surrender fee, my animal is up to date on vaccines, current on heartworm preventative, and spayed or neutered and I can provide documentation from a veterinarian on the dog’s medical history. I am unwilling to pay the owner surrender fee If you are unwilling to pay, explain why: If the dog is taken into rescue by Indy Great Pyrenees Rescue, I agree that this dog is being surrendered because I no longer can care for the pet or want to be responsible for it in anyway. To my knowledge the animal does not display vicious behavior towards humans. I understand if an animal behaviorist determines the animal is not suitable for adoption, it will be euthanized in a humane manner. The animal will be placed in a suitable family home as a companion and pet, and will not be used for testing. I understand that by signing this document, I cannot ask for the animal to be returned to me or my family, no matter what the circumstances. I also understand I will not be able to visit the animal in its new home, and the adopters’ identity or location will not be revealed unless the adopter agrees. I give authorization to my veterinary clinic to release all medical records regarding the have mentioned dog to Indy Great Pyrenees Rescue Inc.. Signature Typed name will serve as a signature.